Political partisanship, laissez-faire attitudes, and COVID-19 behaviours and viewpoints in Canada and the United States.

OBJECTIVE: In the United States, clear partisan differences in responses to COVID-19 have been shown in leadership and elite cueing at the state level as well as in perspectives and behaviours of the citizenry. This study probes differences in political values-particularly the prevalence of laissez-faire attitudes-that might explain the stronger social consensus on pandemic countermeasures seen in Canada. METHODS: Data were obtained from temporally aligned waves of cross-sectional surveys of Canadian and US adults in the first year of the pandemic. Survey questions were used to construct an index of laissez-faire attitudes (LFA) which, along with demographic variables and measures of partisanship, was incorporated into regression models to predict three outcomes: practice of personal mitigation measures (e.g. mask wearing), level of worry about the pandemic, and likeliness to get a vaccine. RESULTS: LFA scores had a strong negative relationship to all three outcomes for Canadians and Americans, albeit with larger effects among the Americans on two outcomes. Overall differences in LFA scores between Americans and Canadians were modest (0.04 on a 0-1 scale). However, Republican Party stalwarts had considerably higher LFA scores and were proportionally more numerous than Conservative loyalists in Canada. While there were partisan differences in LFA scores within Canada, the largest gap by far was between Republicans and Democrats in the USA. Respondents from Canada's Prairie provinces had slightly higher average LFA scores but there were no significant residence effects on outcomes. CONCLUSION: Laissez-faire attitudes that may conflict with public health values and measures are much more prevalent in the USA than in Canada. This difference underpins the limited effects of political partisanship and broad consensus in the Canadian public's responses to the pandemic.

RéSUMé: OBJECTIF: Aux États-Unis, des différences partisanes évidentes au niveau des réactions face au COVID-19 ont été mises en évidence pour ce qui est du leadership et des indications données par l'élite au niveau de l'État, ainsi que des perspectives et des comportements des citoyens. Cette étude examine les différences de valeurs politiques, en particulier la prévalence de comportements de type « laissez-faire ¼, susceptibles d'expliquer le consensus social plus fort observé au Canada concernant les contre-mesures à prendre en cas de pandémie. MéTHODES: Les données ont été obtenues à partir de séries d'enquêtes transversales alignées temporellement auprès d'adultes canadiens et américains durant la première année de la pandémie. Les questions de l'enquête ont été utilisées pour élaborer un indice de laissez-faire (LFA) qui, avec des variables démographiques et des indicateurs de partisanerie, a été incorporé dans des modèles de régression pour prédire trois résultats : la mise en œuvre de mesures d'atténuation personnelles (par exemple, le port d'un masque), le niveau d'inquiétude face à la pandémie et la probabilité de se faire vacciner. RéSULTATS: Les scores LFA ont une forte relation négative avec les trois résultats pour les Canadiens et les Américains, bien qu'avec des effets plus importants chez les Américains pour deux résultats. Les différences globales dans les scores LFA entre les Américains et les Canadiens étaient modestes (0,04 sur une échelle de 0 à 1). Toutefois, les fervents du parti républicain ont obtenu des scores nettement plus élevés au niveau du LFA et étaient proportionnellement plus nombreux que les partisans du parti conservateur au Canada. S'il existe des différences partisanes dans les scores du LFA au sein du Canada, l'écart le plus important, et de loin, se situe entre les républicains et les démocrates aux États-Unis. Les répondants des provinces des Prairies au Canada ont obtenu des scores moyens légèrement plus élevés pour le LFA, mais il n'y a pas eu d'effets significatifs du lieu de résidence sur les résultats. CONCLUSION: Les attitudes de « laissez-faire ¼ pouvant entrer en conflit avec les valeurs et les mesures de santé publique sont beaucoup plus répandues aux États-Unis qu'au Canada. Cette différence explique les effets limités de la partisanerie politique et du consensus général quant aux réactions du public canadien face à la pandémie.

Case Report: What-or who-killed Frank Ramsey? Some reflections on cause of death and the nature of medical reasoning.

Philosopher Frank Ramsey died in 1930 aged only 26. There has been much speculation about the nature of his final illness and the sequence of events which led to his death. To prepare this case report, we traced Ramsey's medical records and combined them with an extensive and unique dataset of contemporaneous sources. We use these to evaluate three possible explanations for Ramsey's illness and its unexpectedly fatal trajectory-infectious (Weil's disease), autoimmune (primary sclerosing cholangitis) and obstructive (gallstones). We explore how uncertainty surrounding each of these possibilities might have influenced Ramsey's doctors' thoughts and actions, including their ill-fated decision to perform the emergency operation that appears to have precipitated his final decline. We then reflect on the unfinished opus on which Ramsey was working when he died-on the nature of truth and how humans reason under conditions of uncertainty. We end with some thoughts linking Ramsey's death to his philosophy.

Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.

BACKGROUND: The goal of this study was to determine the relationship between all-cause, risk-adjusted, in-hospital mortality after coronary artery bypass graft surgery and the proportion of preventable in-hospital deaths as a measure of quality of care at an institution level. METHODS AND RESULTS: We conducted a retrospective analysis of 347 randomly selected in-hospital deaths after isolated coronary artery bypass graft surgery at 9 institutions in Ontario over the period of 1998 to 2003. Nurse-abstracted chart summaries were reviewed by 2 experienced cardiac surgeons who were blinded to patient, surgeon, and hospital and used a standardized implicit tool to identify preventable death. A third reviewer reassessed all cases in which the first 2 reviewers disagreed. Rates of preventable deaths were estimated for each hospital and compared with all-cause mortality rates. A structured adverse event audit completed by each surgeon-reviewer was used to identify quality improvement opportunities for the preventable deaths. A total of 111 of 347 deaths (32%) were judged preventable despite a low risk-adjusted mortality range (1.3% to 3.1%) across hospitals. No significant correlation was found between all-cause, risk-adjusted in-hospital mortality rates and the proportion of preventable deaths at the hospital level (Spearman coefficient, -0.42; P=0.26). A large proportion of preventable deaths were related to problems in the operating room (86%) and intensive care unit (61%). Many deaths were associated with deviations in perioperative care (32% based on concurrence of 2 reviewers, and another 42% in cases in which 1 reviewer reached that opinion). CONCLUSIONS: Approximately one third of in-hospital coronary artery bypass graft deaths were judged preventable by surgeon reviewers. All-cause risk-adjusted mortality rates are convenient measures of institutional quality of care but were not correlated with preventable mortality in our jurisdiction. Providers should conduct detailed adverse event audits to drive meaningful improvements in quality.

Impact of patient and target-vessel characteristics on arterial and venous bypass graft patency: insight from a randomized trial.

BACKGROUND: The purpose of this investigation was to determine optimal patient and target-vessel characteristics to maximize arterial and venous graft patency on the basis of data from a large clinical trial. METHODS AND RESULTS: Angiographic data on 440 radial artery grafts and 440 saphenous vein grafts were analyzed with methodology to account for within-patient clustering. Multivariable models that incorporated patient demographic, operative, anatomic, and postdischarge medical management were constructed to determine predictors of graft occlusion. Radial artery use was strongly protective against graft occlusion at 1 year after adjustment for all covariates, with a larger protective effect seen in women (P=0.05 for a subgroup-by-treatment interaction). Among all grafts, diabetes and small target-vessel diameter were associated with an increased risk of graft occlusion, and grafting to a target vessel with more severe proximal stenosis was associated with a decreased risk of graft occlusion. With regard to gender, radial artery graft occlusion at 1 year occurred in similar proportions of men (8.6%) and women (5.3%, P=0.6), whereas, for saphenous vein grafts the comparable occlusion rates were 12.0% and 23.3% respectively (P=0.02). A history of peripheral vascular disease was associated with an elevated risk of radial artery occlusion but was not associated with early vein graft occlusion (P=0.02 for a subgroup-by-treatment interaction). CONCLUSIONS: Patients benefit from radial artery-coronary artery bypass conduits as opposed to saphenous vein conduits, and this effect is especially strong in women. Small target-vessel size adversely affected graft patency, and grafting to a target vessel with more severe proximal stenosis improved graft patency.

A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts.

BACKGROUND: In the past decade, the radial artery has frequently been used for coronary bypass surgery despite concern regarding the possibility of graft spasm. Graft patency is a key predictor of long-term survival. We therefore sought to determine the relative patency rate of radial-artery and saphenous-vein grafts in a randomized trial in which we controlled for bias in the selection of patients and vessels. METHODS: We enrolled 561 patients at 13 centers. The left internal thoracic artery was used to bypass the anterior circulation. The radial-artery graft was randomly assigned to bypass the major vessel in either the inferior (right coronary) territory or the lateral (circumflex) territory, with the saphenous-vein graft used for the opposing territory (control). The primary end point was graft occlusion, determined by angiography 8 to 12 months postoperatively. RESULTS: Angiography was performed at one year in 440 patients: 8.2 percent of radial-artery grafts and 13.6 percent of saphenous-vein grafts were completely occluded (P=0.009). Diffuse narrowing of the graft (the angiographic "string sign") was present in 7.0 percent of radial-artery grafts and only 0.9 percent of saphenous-vein grafts (P=0.001). The absence of severe native-vessel stenosis was associated with an increased risk of occlusion of the radial-artery graft and diffuse narrowing of the graft. Harvesting of the radial artery was well tolerated. CONCLUSIONS: Radial-artery grafts are associated with a lower rate of graft occlusion at one year than are saphenous-vein grafts. Because the patency of radial-artery grafts depends on the severity of native-vessel stenosis, such grafts should preferentially be used for target vessels with high-grade lesions.

Socioeconomic status and mortality after acute myocardial infarction.

BACKGROUND: Gradients that link socioeconomic status and cardiovascular mortality have been observed in many populations, including those of countries that provide publicly funded comprehensive medical coverage. The intermediary causes of such gradients remain poorly elucidated. OBJECTIVE: To examine the relationships among socioeconomic status, other health factors, and 2-year mortality rates after acute myocardial infarction (MI). DESIGN: Prospective cohort study. SETTING: Ontario, Canada. PATIENTS: 3407 patients who were hospitalized for acute MI in 53 large-volume hospitals in Canada from December 1999 to February 2003. MEASUREMENTS: The authors obtained self-reported measures of income and education and developed profiles of the patients' prehospitalization cardiac risks and comorbid conditions. To create these profiles, the authors used the patients' self-reports and retrospectively linked no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, ethnicity, social support, cardiovascular history and risk, comorbid conditions, and selected in-hospital process factors. RESULTS: Income was strongly and inversely correlated with 2-year mortality rate (crude hazard ratio for high-income vs. low-income tertile, 0.45 [95% CI, 0.35 to 0.57]; P < 0.001). However, after adjustment for age and preexisting cardiovascular events or conventional vascular risk factors, the effect of income was greatly attenuated (adjusted hazard ratio for high-income vs. low-income tertile, 0.77 [CI, 0.54 to 1.10]; P = 0.150). Noncardiovascular comorbid conditions and in-hospital process factors had negligible explanatory effect. LIMITATIONS: Previous cardiovascular risks were ascertained through self-report or retrospectively through the longitudinal tracking of the hospitals' administrative databases. The study began with a cohort of patients who had an index cardiac event rather than with asymptomatic individuals. CONCLUSIONS: Age, past cardiovascular events, and current vascular risk factors accounted for most of the income-mortality gradient after acute MI. This observation suggests that the "wealth-health gradient" in cardiovascular mortality may be partially ameliorated by more rigorous management of known risk factors among less affluent persons. *For a list of members of the SESAMI Study Group, see the Appendix.